Programmes that show people with osteoarthritis how to exercise safely may slightly improve pain scores, self-belief and social function, but participants also report the myth that discomfort while exercising indicates on-going harm.
The review combines evidence from 21 randomised controlled trials evaluating exercise in hip or knee osteoarthritis with 12 studies where people receiving the intervention were interviewed about the impact of exercise on their disease. Participants were men and women aged older than 45 years.
Analysis of the randomised trials provides moderate- to low-quality evidence that exercise slightly improved pain and function and gave small improvements in depression, social function and people’s belief in their physical capability.
Patient interviews highlight a common misconception that exercise can do more harm than good, and the important role healthcare professionals play in challenging these beliefs. Programmes that include clear, tailored instruction and provide opportunities to participate in supervised or group exercise may improve exercise uptake in people with hip and/or knee osteoarthritis.
Why was this study needed?
Osteoarthritis is the most common form of joint disease, affecting at least eight million people in the UK. It can affect any joint, but it most commonly affects the knees, hips, neck and back, toes and fingers.
Exercise is recommended by NICE to reduce joint pain and improve mobility in people with osteoarthritis, but some studies have shown that exercise has additional benefits. It can also boost emotional well-being and lead to greater self-reliance, reduced disability and helplessness.
As there is no summary of the evidence to link physical, emotional and behavioural effects of osteoarthritis, and the potential of exercise to address these, the researchers reviewed evidence on the impact of exercise on people's pain, physical and emotional wellbeing, and aimed to determine the most effective ways to deliver exercise in this population.
What did this study do?
This study identified 21 randomised controlled trials (2,372 people) evaluating the effects of exercise on physical and mental health of men and women aged over 45 with hip and/or knee osteoarthritis. These were conducted in high-income countries including Europe. It also included a synthesis of qualitative evidence from patient interviews (12 studies, 197 participants). This research included studies that had asked about their perceptions of exercise and effects on pain and wellbeing alongside an exercise intervention.
The trials were differed by the population and participants examined. The trials also varied by the type, setting and time period of the exercise intervention. Most interventions (15 studies) were delivered by trained professionals who were either fitness/exercise instructors or physiotherapists. The variations in study characteristics made it hard for the researchers to draw clear general conclusions. Overall risk of bias in the trials was low, but because people knew they were taking part in exercise, this may have increased any perceived benefits.
What did it find?
- Exercise reduced pain by 6% (95% confidence interval [CI] -9 to -4%; 9 studies, 1,058 participants, moderate quality). This equated to a reduction in pain score from 6.5 to 5.3 on a scale of 0 to 20. There was no difference in physical function (absolute reduction of 5.6%; 95% CI ‑7.6% to 2.0%; 13 studies, 1,599 participants, moderate quality).
- Exercise may slightly improve people’s belief in their own capabilities (1.66% improvement; 95% CI 1.08 to 2.20; 11 studies, 1,138 participants, low quality) and symptoms of depression (2.4% reduction; 95% CI -0.47 to ‑0.5; 7 studies, 919 participants, moderate quality) but no effect on anxiety.
- Social function increased by 7.9% (95% CI 4.1 to 11.6; 5 studies, 576 participants, low quality). This equated to an improvement in social function score from 73.6 to 81.5 on a scale of 0 to100.
- Interviews with participants found that pain, joint stiffness, tiredness, other illnesses and people's views of their physical fitness restricted the type and amount of exercise they felt able to do. Pain during exercise was also often thought to be causing additional joint damage, so people avoided activity for fear of causing more harm.
- Participants also said that clear instructions from healthcare professionals outlining exactly what exercises to do, what to avoid, and what they might experience during the exercise helped to reassure them that exercise is safe and beneficial. Most interviewees thought that rehabilitation programmes that included a way to participate in exercise had physical, emotional and social benefits. Providing exercise recommendations that are tailored to individual preferences, abilities and needs was also important.
What does current guidance say on this issue?
The 2014 NICE guideline on osteoarthritis recommends exercise, irrespective of age, other conditions, pain severity or disability. This should include local muscle strengthening and general aerobic fitness. Stretching and manipulation is also recommended for hip osteoarthritis.
It is not specified whether exercise should be provided by the NHS or whether the healthcare professional should advise and encourage people to exercise independently. It does recommend that clinicians judge how best to ensure participation, depending on individual needs, circumstances and self-motivation, and the availability of local facilities.
Wider evidence on physiotherapy for musculoskeletal health and wellbeing was published by NIHR Dissemination Centre in July 2018.
What are the implications?
Overall this review adds evidence from patient interviews that could help healthcare professionals to encourage more effective uptake of exercise in this group. It reinforces existing evidence about the benefits of exercise for people with arthritis with slight improvements in pain and function, indicating how these benefits could be maximised.
Specific suggestions are that rehabilitation programmes could educate people about the causes and potential disease course of osteoarthritis, challenging the belief that exercise causes harm and reassuring people that it is safe and beneficial. The researchers suggest that advice is tailored to each individual patient, managing expectations about the ways in which exercise might improve or worsen their symptoms or leave pain and mobility unchanged.
Physiotherapists already have a role in offering personalised advice and encouragement and this review provides further evidence for them.
Citation and Funding
Hurley M, Dickson K, Hallett R, et al. Exercise interventions and patient beliefs for people with hip, knee or hip and knee osteoarthritis: a mixed methods review. Cochrane Database Syst Rev. 2018;(4):CD010842.
This project was supported by an Educational Grant, Number 20163 from Arthritis Research UK.
NICE. Osteoarthritis: care and management. CG177. London: National Institute for Health and Care Excellence; 2014.
NIHR DC. Moving forward - physiotherapy for musculoskeletal health and wellbeing. Themed review. Southampton: National Institute for Health Research Dissemination Centre; 2018.
Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre